Treatment of Brucella endocarditis: 15 years of clinical and surgical experience

Clinical Characteristics and Outcome of Brucella Endocarditis: A Case Series

Purpose

 Brucella endocarditis is a rare complication with a high mortality risk. This research aims to evaluate patients diagnosed with Brucella Endocarditis and review clinical characteristics, diagnosis, and treatment strategies to serve as a foundation for future research in managing Brucella endocarditis and improving patient care and outcomes.

Patients and Methods

This retrospective study reviewed the medical records of patients diagnosed with Brucella endocarditis from 2011 to 2022. The study included patients of all ages and genders who were diagnosed based on positive serum serology or blood culture in conjunction with clinical presentation. Diagnostic criteria for endocarditis were based on evidence of endocardial involvement, as confirmed by echocardiographic findings consistent with infective endocarditis. Descriptive statistics were used for data analysis.

Results

Nine patients were included in this study. The most common presenting symptom was shortness of breath. Treatment regimens included Doxycycline and Rifampicin, always in combination with other antibiotics. Surgical intervention was necessary for two-thirds of the patients. Complications, such as septic shock, stroke, and heart failure, were observed in most cases. Six patients achieved clinical and microbiological cures, while one-third of the patients died. The deaths were primarily attributed to patients being deemed unsuitable for surgery due to a high surgical risk, based on their comorbidities and clinical assessments.

Conclusion

This study highlights the importance of initiating an appropriate antibiotic regimen in a timely manner. Particularly in patients with pre-existing heart diseases, surgical intervention can significantly improve patient outcomes and reduce complications associated with Brucella endocarditis.

Brucellosis involving the aorta and iliac arteries: a systematic review of 130 cases

Objective: Brucellosis, the most common bacterial zoonosis, poses a serious threat to public health in endemic regions. Cardiovascular complications of brucellosis, mostly pericarditis or endocarditis, are the leading cause of brucellosis-related death. Complications involving the aorta and iliac arteries are extremely rare but can be life-threatening. Our objective was to identify and review all reported cases of aortic and iliac involvement in brucellosis to provide a deep, up-to-date understanding of the clinical characteristics and management of the disease. Methods: Online searches in PubMed, Web of Science, China National Knowledge Infrastructure, and the Chinese Wanfang database were conducted to collect articles reporting cases of brucellosis with aortic and iliac artery involvement. All data in terms of patient demographics, diagnostic methods, clinical manifestations, and treatment regimens and outcomes were extracted and analyzed in this systematic review. Results: A total of 79 articles were identified, reporting a total of 130 cases of brucellosis with aortic and iliac artery involvement. Of the 130 cases, 110 (84.5%) were male individuals and 100 (76.9%) were over 50 years old. The patients had an overall mortality rate of 12.3%. The abdominal aorta was most commonly involved, followed by the ascending aorta, iliac artery, and descending thoracic aorta. Arteriosclerosis, hypertension, and smoking were the most common comorbidities. There were 71 patients (54.6%) who presented with systemic symptoms of infection at the time of admission. Endovascular therapy was performed in 56 patients (43.1%), with an overall mortality rate of 3.6%. Open surgery was performed in 52 patients (40.0%), with an overall mortality rate of 15.4%. Conclusion: Aortic and iliac involvement in brucellosis is extremely rare but can be life-threatening. Its occurrence appears to be associated with the male gender, an older age, arteriosclerosis, and smoking. Although the number of reported cases in developing countries has increased significantly in recent years, its incidence in these countries may still be underestimated. Early diagnosis and therapeutic intervention are critical in improving patient outcomes. Endovascular therapy has become a preferred surgical treatment in recent years, and yet, its long-term complications remain to be assessed.

Re-do pericardial reconstruction of the aortic valve in Brucella endocarditis

We report a 12-year-old boy who had undergone an auto-pericardial aortic valve implantation 3 years ago for rheumatic aortic regurgitation. He presented with Brucella endocarditis of the auto-pericardial leaflets with new-onset severe aortic regurgitation, congestive cardiac failure and systemic sepsis. He had an aortic root abscess with multiple pseudoaneurysms in relation to the aortic sinus. Following medical stabilisation, he underwent re-do surgery with debridement of the root abscess, closure of the pseudoaneurysms, excision of the auto-pericardial aortic leaflets and reconstruction of the aortic valve with donor pericardium. He had an uneventful recovery and is asymptomatic on follow-up.

Brucella Prosthetic Valve Endocarditis: A Systematic Review

Objective

Brucella prosthetic valve endocarditis is a rare but a life-threatening complication of brucellosis. It remains a diagnostic challenge. Optimal treatment of Brucella prosthetic valve endocarditis is debated. Available data is limited to case reports or small case series. The purpose of this study was to systematically review all published cases of Brucella prosthetic valve endocarditis in the literature.

Method

A systematic review of PubMed database, Google, Google Scholar, and Scopus (From January 1974 to the present) for studies providing epidemiological, clinical and microbiological data as well as data on treatment and outcomes of Brucella prosthetic valve endocarditis was performed.

Results

A total of 51 reported cases were reviewed. Brucella melitensis (45%) and Brucella abortus (11.7%) were the most frequently isolated species. Most common type of prosthesis valve was mechanical prothesis (84.3%) and ten patients had double valve prosthesis (19.6%). Fever and dyspnea were present in 100% and 37.2% of the cases, respectively. The diagnosis was set with echocardiographic finding in 30 cases (93.7%), which revealed vegetation in 27 cases (84.3%). Most used antibiotics were rifampicin, doxycycline and aminoglycoside or cotrimoxazole. No deaths were noted in patients treated by combined medical and surgical treatment, but mortality was noted in 27.7% of the cases treated by antibiotics alone (p = 0.006).

Conclusion

This systematic review highlights diagnostic challenges and demonstrates that surgery improved outcome by reducing mortality in patients treated with the combined surgical and medical treatment option. Brucellosis should be considered in the differential diagnosis of prosthetic valve endocarditis in patients residing in or traveling to areas of endemicity.

Brucella involving the heart: a hidden disease

Brucellosis is a multisystemic disease with serious cardiac involvement mainly endocarditis. It is a lethal but rare complication involving congenital, prosthetic and even native valves. Positive hemoculture confirm the diagnosis. Brucella endocarditis is known for large vegetations and surgery is the treatment of choice. Abscess formation can be seen in untreated patients. An 80-year-old male patient presented with fever, cough and progressive shortness of breath for 14 days. His known history revealed a poorly treated brucellosis 18 months ago due to noncompliance. Four months later, he presented for recurrent fever. Physical examination showed a systolic aortic murmur radiating to the carotid. Blood cultures were negative; however, blocking antibodies were 1/2560. Echocardiography showed calcified aortic stenosis. Transesophageal echocardiogram (TEE) showed an abscess formation at the level of the non-coronary cusp. A quadritherapy was initiated involving Ceftriaxone, gentamicin, doxycycline, and trimethoprim-sulfamethoxazole (shortage in molecule replaced by ciprofloxacin). Patient underwent surgery. An aortic valve bioprostheses was successfully implanted one week after initiating antibiotics. Intraoperative cultures were negative. A post-operative transthoracic echocardiography revealed a moderate periprosthetic aortic leak with a mean gradient of 18mmHg. He was discharged 18 days following surgery on doxycycline, rifampicin, and ciprofloxacin for 3 more months, with adequate follow up. The challenge remains in the timing of diagnosis which affects the prognosis of the disease. Early diagnosis and effective medical and surgical management are essential.

Brucella prosthetic valve endocarditis with septic and cardiogenic shock

A young man with aortic prosthetic valve replacement, presented with prolonged fever and diagnosed with brucella endocarditis based on positive transthoracic echo findings with high titer positive brucellacapt serology. He was started on medical treatment with doxycycline and rifampin to which gentamicin and ceftriaxone were added and he was planned for surgical intervention. Unfortunately, the patient developed cardiogenic with septic shock before performing surgery and died within 24 h soon after admission.

Brucella Endocarditis of the Native Mitral Valve Treated With Antibiotics

Brucellosis is a rare zoonotic infection with a low annual incidence in the United States. Infective endocarditis secondary to brucellosis involving native or prosthetic valves is contemplated to be an extremely rare entity. As Brucella can present with non-specific sign and symptoms, clinicians need to have a higher degree of suspicion of Brucella endocarditis in culture-negative endocarditis patients, particularly those who have a history of exposure to farm animals. Timely diagnosis with appropriate management using antibiotics can prevent valvular damage and restore the valve's structural integrity. In this case report, we present a case of culture-negative, serology-proven Brucella endocarditis of native mitral valve, with an initial presentation of stroke that was successfully treated with combination antibiotic therapy.

Successful Management of Prosthetic Valve Brucella Endocarditis with Antibiotherapy Alone

Objectives

To report a case of mechanical aortic prosthesis Brucella endocarditis successfully treated with antibiotics alone.Materials and methods: We describe a clinical case and present a review of the literature.

Results

A 60-year-old female farmer with a mechanical aortic prosthetic valve presented with low back pain and fever. She was diagnosed with prosthetic valve Brucella mellitensis endocarditis and was cured with antibiotic therapy alone. Few cases of successfully treated prosthetic valve Brucella endocarditis without surgery have been reported.

Conclusion

Prosthetic valve Brucella endocarditis usually requires surgical valve replacement. However, selected patients may be successfully treated with antibiotic therapy alone.

LEARNING POINTS

Brucella endocarditis is responsible for most fatal cases of brucellosis.Brucellosis relapse after treatment in patients with a cardiac valve prosthesis should arouse suspicion for endocarditis.Long-term medical treatment alone can be successful in selected patients with Brucella endocarditis, even in those with prosthetic valve endocarditis..

An Uncommon Presentation of Brucella Endocarditis Masquerading as Neurobrucellosis

Brucella endocarditis is a rare but a severe complication of brucellosis, observed in less than 2% of cases. It is the main cause responsible for up to 80% of deaths in brucellosis. Herein, we present a case of brucella endocarditis that developed on a native aortic valve, but presented to us with fever for several months and acute neurological symptoms. This case report signifies the importance of considering brucella endocarditis as one of the differentials in patients presenting with Pyrexia of Unknown Origin (PUO) and Central Nervous System (CNS) manifestations.

Brucellar Aortitis and Meningoencephalitis in an Adolescent

Brucellosis can affect any organ system and result in possible complications. We present an adolescent male who had brucellar aortitis and meningitis simultaneously. Brucellar aortic involvement is a rare complication of brucellosis and can occur without concomitant endocarditis. Here, the patient was managed with prolonged antibiotic therapy without any surgery.

A comparison of different antibiotic regimens for the treatment of infective endocarditis

BACKGROUND

Infective endocarditis is a microbial infection of the endocardial surface of the heart. Antibiotics are the cornerstone of treatment, but their use is not standardised, due to the differences in presentation, populations affected and the wide variety of micro-organisms that can be responsible.

OBJECTIVES

To assess the existing evidence about the clinical benefits and harms of different antibiotics regimens used to treat people with infective endocarditis.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE Classic and EMBASE, LILACS, CINAHL and the Conference Proceedings Citation Index on 30 April 2015. We also searched three trials registers and handsearched the reference lists of included papers. We applied no language restrictions.

SELECTION CRITERIA

We included randomised controlled trials assessing the effects of antibiotic regimens for treating possible infective endocarditis diagnosed according to modified Duke's criteria. We considered all-cause mortality, cure rates and adverse events as the primary outcomes. We excluded people with possible infective endocarditis and pregnant women.

DATA COLLECTION AND ANALYSIS

Three review authors independently performed study selection, 'Risk of bias' assessment and data extraction in duplicate. We constructed 'Summary of findings' tables and used GRADE methodology to assess the quality of studies. We described the included studies narratively.

MAIN RESULTS

Four small randomised controlled trials involving 728 allocated/224 analysed participants met our inclusion criteria. These trials had a high risk of bias. Drug companies sponsored two of the trials. We were unable to pool the data due to the heterogeneity in outcome definitions and the different antibiotics used.The included trials compared the following antibiotic schedules. The first trial compared quinolone (levofloxacin) plus standard treatment (anti-staphylococcal penicillin (cloxacillin or dicloxacillin), aminoglycoside (tobramycin or netilmicin) and rifampicin) versus standard treatment alone reporting uncertain effects on all-cause mortality (8/31 (26%) with levofloxacin plus standard treatment versus 9/39 (23%) with standard treatment alone; RR 1.12, 95% CI 0.49 to 2.56, very low quality evidence). The second trial compared daptomycin versus low-dose gentamicin plus an anti-staphylococcal penicillin (nafcillin, oxacillin or flucloxacillin) or vancomycin. This showed uncertain effects in terms of cure rates (9/28 (32.1%) with daptomycin versus 9/25 (36%) with low-dose gentamicin plus anti-staphylococcal penicillin or vancomycin, RR 0.89 95% CI 0.42 to 1.89; very low quality evidence). The third trial compared cloxacillin plus gentamicin with a glycopeptide (vancomycin or teicoplanin) plus gentamicin. In participants receiving gentamycin plus glycopeptide only 13/23 (56%) were cured versus 11/11 (100%) receiving cloxacillin plus gentamicin (RR 0.59, 95% CI 0.40 to 0.85; very low quality evidence). The fourth trial compared ceftriaxone plus gentamicin versus ceftriaxone alone and found no conclusive differences in terms of cure (15/34 (44%) with ceftriaxone plus gentamicin versus 21/33 (64%) with ceftriaxone alone, RR 0.69, 95% CI 0.44 to 1.10; very low quality evidence).The trials reported adverse events, need for cardiac surgical interventions, uncontrolled infection and relapse of endocarditis and found no conclusive differences between comparison groups (very low quality evidence). No trials assessed septic emboli or quality of life.

AUTHORS' CONCLUSIONS

Limited and very low quality evidence suggested that there were no conclusive differences between antibiotic regimens in terms of cure rates or other relevant clinical outcomes. However, because of the very low quality evidence, this needs confirmation. The conclusion of this Cochrane review was based on randomised controlled trials with high risk of bias. Accordingly, current evidence does not support or reject any regimen of antibiotic therapy for treatment of infective endocarditis.

Brucella endocarditis as a late onset complication of brucellosis

Brucella endocarditis (BE) is a rare but life threatening complication of brucellosis. We present a case report of a patient with relapsing brucellosis complicated with aortic valve endocarditis. The patient underwent valve replacement and required prolonged antibiotic treatment because of rupture of the noncoronary leaflet and development of congestive heart failure. Since the onset of endocarditis in patients with brucellosis is not known, proper follow-up is required in order to identify any late onset complications, especially in endemic areas.

Successful Medical Treatment of Prosthetic Mitral Valve Endocarditis Caused by Brucella abortus

Although Brucella endocarditis is a rare complication of human brucellosis, it is the main cause of the mortality in this disease. Traditionally, the therapeutic approach to endocarditis caused by Brucella species requires a combination of antimicrobial therapy and valve replacement surgery. In the literature, only a few cases of mitral prosthetic valve endocarditis caused by Brucella species have been successfully treated without reoperation. We present a case of a 42-year-old man with a prosthetic mitral valve infected by Brucella abortus who was cured solely by medical treatment.

Brucella endocarditis in a non-endemic area presenting as pyrexia of unknown origin

A 67-year-old man with type 2 diabetes mellitus and hypertension since 7 years presented with a 3-month history of low-grade fever and malaise. Cardiac auscultation revealed the presence of an ejection systolic murmur in the primary aortic area. Most of the investigations for febrile illness were reported normal. His two-dimensional (2D) echocardiogram revealed a calcified aortic valve with mild aortic stenosis. In view of the prolonged fever and calcified aortic valve with mild aortic stenosis, a transoesophageal echocardiogram was performed, which showed small vegetation noted on right coronary cusp about 2.2 mm with free independent mobility. Blood culture was positive for Brucella spp from all the three venepuncture sites. Medical therapy for brucellosis was given with ciprofloxacin, doxycycline, co-trimoxazole and streptomycin, resulting in complete recovery. Brucella endocarditis is a rare, mostly ignored and missed clinical infection. It requires a high index of clinical suspicion for prompt diagnosis and treatment.

Successful management of native-valve Brucella endocarditis with medical therapy alone

A 71-year-old Asian-Indian male agriculturist presented with fever since 3 months. Clinical examination revealed hepatosplenomegaly and an early diastolic murmur in the aortic area. Echocardiography confirmed aortic regurgitation with large vegetations on the aortic valve leaflets, and also showed mild left ventricular dilatation with systolic dysfunction. Although blood cultures were persistently sterile, serology for Brucella was strongly positive. On retrospective questioning, the patient confirmed frequent occupational exposure to cattle. Surgical intervention was offered, but refused by the patient on financial grounds. Medical therapy for brucellosis with rifampicin, doxycycline and streptomycin resulted in complete and durable recovery.

Brucella endocarditis: an occupational hazard!

A young man presented with a 2-month history of fever and malaise. Cardiac auscultation revealed the presence of a diastolic murmur. Subsequently, a cardiac echocardiogram was done, which showed a large vegetation adherent to an anterior mitral leaflet. The blood culture was positive for Brucella species. The patient was given antibiotic therapy for brucellosis and referred for surgery. Brucella endocarditis is one of the rarest, yet most notorious complications of this infection. This condition requires a high degree of clinical suspicion in order to facilitate prompt diagnosis and treatment.

Medical versus medical and surgical treatment for brucella endocarditis

This review was undertaken to determine the role of surgery in the treatment of brucella endocarditis. All English and French articles reporting brucella endocarditis (1966 to 2011) in PubMed, Google, and Scopus were reviewed. In all, 308 cases were identified, and linear and logistic regression was performed. Surgery improved outcomes by decreasing mortality from 32.7% in the medical treatment only group to 6.7% in the combined surgical and medical treatment group (p<0.001). This association was still significant while controlling for other contributing factors. In the absence of a controlled trial, we recommend the utmost vigilance and consideration of surgical management in treating such patients.

Involvement of the aorta in brucellosis: the forgotten, life-threatening complication. A systematic review

Human brucellosis is a disease of protean manifestations, and has been implicated in complications and focal disease in many human organ systems. However, little is collectively known about the background, the course, the clinical characteristics, the diagnostic issues raised, and the short- and long-term therapeutic approaches in patients with aortic involvement as a complication of brucellosis. With the aim to glean from the literature useful information to better understand and manage this complication, a computerized search without language restriction was conducted using PubMed and SCOPUS. An article was considered eligible for inclusion in the systematic review if it reported data on patients with involvement of the aorta due to a Brucella infection. The epidemiologic and clinical characteristics of 44 cases of brucellar aortic involvement found through the systematic review of the literature were analyzed together with those of two new cases that we treated in the recent past. This complication involved the ascending thoracic aorta in 18 cases (in 16 of them as a consequence of brucellar endocarditis), and the descending thoracic aorta or the abdominal aorta in the remaining 30 cases. In the latter it was associated with spondylodiscitis of the lumbar spine in 13 cases. History of or symptoms indicative of brucellosis were not universally present. Brucellar aortic involvement represents a possibly underdiagnosed and underreported complication with major morbidity and mortality potential. Experience with novel invasive therapeutic approaches remains limited. Early suspicion through detailed history and diagnosis, aided by advances in aortic imaging, would allow for better planning of therapeutic interventions.

Presentation of two cases diagnosed with Brucella endocarditis

Brucellosis is an important disease in developing countries. Endocarditis is a complication of brucellosis with the highest mortality. Although the most generally accepted therapy is the combination of medication and surgery, it has been reported that antibiotic treatment only might also be adequate. We present two cases for whom antibiotic treatments were initiated, and a follow-up surgery was planned for one of them. The surgery could not be done due to death of the patient, but the other patient fully recovered with antibiotic treatment only. Optimum treatment and prognostic criteria are not well defined for brucella endocarditis, but medical therapy alone can be considered for some chosen patients.

Treatment protocol and relapses of brucella endocarditis; cotrimoxazole in combination with the treatment of brucella endocarditis

Antibiotic treatment, surgical intervention and postoperative antibiotic regimens are recommended for the treatment of brucella endocarditis (BE). Our clinical antibiotic regimens involve a triple antibiotic regimen for treating BE before the operation. The combination of three antibiotics is continued for at least six months and until the titres of the Wright serologic test are diminished to 1:160 levels. In this study, our aim was to evaluate the effects of combined medical and surgical treatments on survival and relapse rates in the periods of mid to late terms. We investigated 13 patients who were treated between January 1993 and June 2009. Our clinical observations led us to use a combination of rifampicin (900 mg twice a day), streptomycin (12 to 16 mg/kg/24 h intramuscularly) and doxycycline (200 mg/kg twice a day); rifampicin, tetracycline (8 mg/kg three times a day) and cotrimoxazole (15 mg/kg twice a day) or rifampicin, doxycycline and cotrimoxazole regimen for treating BE before the operation. This treatment should be continued for at least six months after surgery in order to prevent relapses.